Left Knee - Chondromalacia Patella — DVA claim example

Diagnostic Assessment — Left Knee - Chondromalacia Patella

Example 1 of 3 · fictitious patient (Veteran A)

Diagnostic Assessment

Left Knee - CHONDROMALACIA PATELLA

Balance of Probabilities SOP 2/2019 Reasonable Hypothesis SOP 1/2019

ADF History

The veteran enlisted in the Royal Australian Air Force as an Aircraft Technician on 18 Apr 1988 and was discharged on 22 October 1999 at the rank of Corporal.

Occupational History

As an Aircraft Technician in the RAAF, the veteran the veteran was exposed to numerous occupational hazards including repetitive kneeling, squatting, and climbing during aircraft maintenance activities. His role involved working in confined spaces, particularly during Fuel Tank Entry (FTE) duties which required specialized medical clearance. He was regularly exposed to aviation fuels, hydraulic fluids, solvents, and other chemicals. The physical demands of his job included heavy lifting of aircraft components, prolonged standing on hard surfaces, awkward positioning to access aircraft parts, and repetitive physical movements. He was also required to maintain military fitness standards involving regular physical training.

History

The veteran an Aircraft Technician in the Royal Australian Air Force, developed bilateral knee pathology including chondromalacia patella with bilateral patellar chondral fissuring as documented on MRI in December 2020. No specific knee complaints were documented during his service period, suggesting this condition may have developed gradually over time due to the cumulative effects of his physically demanding military duties.

Timeline

• 23 October 2018: MRI bilateral knees performed showing bilateral patellar chondral fissuring. "Left Knee - Mild marrow edema posterior patella" Results indicated significant findings for the left knee including normal thickness but irregular patella cartilage with full- thickness fissuring. The MRI also revealed a horizontal, non-displaced tear in the anterior horn of the left lateral meniscus. The patellar chondral fissuring represents softening, fibrillation, and erosion of the articular cartilage consistent with chondromalacia patella. The bilateral nature of the findings suggests systemic stress consistent with occupational demands rather than a single traumatic event.

Symptoms

At the time of diagnosis, the veteran presented with recurrent or chronic patellofemoral pain. The MRI findings of left patellar chondral fissuring with irregularity are characteristic of chondromalacia patella, which typically presents with anterior knee pain that worsens with activities that increase patellofemoral joint loading such as climbing stairs, squatting, or

prolonged sitting with the knees flexed. The condition often causes pain and crepitus (crackling sensation) when the knee is flexed and extended.

Currently, the veteran experiences ongoing anterior left knee pain, particularly with activities that load the patellofemoral joint. He reports discomfort when kneeling, squatting, or climbing stairs, and experiences a sensation of grinding or crepitus with knee movement. The pain is typically aggravated by prolonged sitting with knees bent, and he finds it difficult to rise from a seated position after remaining stationary for extended periods. The left knee may be more symptomatic than the right, consistent with the additional finding of marrow edema in the posterior patella.

Imaging

23 October 2018: MRI left knee showed: "There is no significant joint effusion. Mild marrow edema posterior patella. No marrow edema of the tibia. The anterior and posterior cruciate ligaments are intact. The medial meniscus is intact with mild degenerative change. The medial femoral cartilage is of normal thickness with minor fissuring. The lateral meniscus demonstrating a horizontal, non-displaced tear anterior horn. The lateral femoral cartilage is of normal thickness with minor fissuring. The lateral collateral ligament and iliotibial tract are normal. The quadriceps and patellar tendons are intact. The patella is centrally located within the trochlea groove. The patella cartilage is of normal thickness but irregular and with full-thickness fissuring."

• What is the formal diagnosis of the condition claimed above? The formal diagnosis is Left Knee Chondromalacia Patella (DVA SOP 2/2019 Balance of Probabilities and 1/2019 Reasonable Hypothesis; ICD-10 code: M22.4).

Chondromalacia patella is a condition characterized by softening, fibrillation, or erosion of the articular cartilage of the patella (kneecap) associated with recurrent or chronic patellofemoral pain. It affects the cartilage on the undersurface of the patella where it articulates with the femur (thigh bone). The condition typically begins with softening of the cartilage, which may progress to fissuring, fibrillation (fraying), and eventually erosion of the cartilage surface.

The pathophysiology involves breakdown of the normally smooth articular cartilage surface that allows for painless gliding of the patella within the trochlear groove of the femur during knee flexion and extension. When this cartilage becomes damaged, the resulting irregular surface creates increased friction and stress during movement, leading to pain and further cartilage deterioration. The condition is distinct from osteoarthritis of the patellofemoral joint, though it may predispose to its development over time.

The veteran has MRI evidence of bilateral patellar chondral fissuring, with the left knee showing patella cartilage of normal thickness but irregular and with full-thickness fissuring. Additionally, there is mild marrow edema in the posterior patella of the left knee, which suggests an active inflammatory process. The left knee also shows a horizontal, non- displaced tear of the anterior horn of the lateral meniscus, indicating additional knee pathology that may be related to or exacerbated by the chondromalacia patella.

The bilateral nature of the findings suggests a systemic cause rather than a single traumatic event, consistent with the cumulative effects of repetitive physical stress on the knees throughout his military service.

• For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? Based on the available documentation, there are no specific records of knee symptoms during Mr.

The veteran's military service from 1992-2004. The condition appears to have developed gradually over time, with the diagnosis made retrospectively based on MRI findings in December 2020. The absence of documented symptoms during service does not preclude the possibility that early manifestations of the condition were present but not reported or were managed without formal medical attention.

When did the veteran first present to a health / medical provider for this condition? The records provided do not document a specific initial presentation for knee symptoms. The earliest documented evidence of the condition is the MRI conducted on January 3, 2023, suggesting that formal medical evaluation for this specific condition occurred around this time.

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed following MRI imaging on January 3, 2023, which demonstrated left knee patellar chondral fissuring consistent with chondromalacia patella. The diagnosis was made by Dr.

Geoffrey the treating doctor, Radiologist, who reported the MRI findings of the left knee showing "patella cartilage of normal thickness but irregular and with full-thickness fissuring."

When did the veteran first present to you (or your practice) for this condition? March 15, 2022

• How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of left knee chondromalacia patella was confirmed through a combination of clinical evaluation and diagnostic imaging.

Key symptoms included anterior knee pain that worsened with activities that loaded the patellofemoral joint such as stair climbing, squatting, and prolonged sitting with flexed knees. Physical examination likely revealed tenderness around the patella and possibly crepitus with patellofemoral movement.

The definitive confirmation came from MRI imaging performed on January 3, 2023, which demonstrated "patella cartilage of normal thickness but irregular and with full-thickness fissuring" in the left knee. Additionally, the MRI showed mild marrow edema in the posterior patella, suggesting an active inflammatory process. These findings are pathognomonic for chondromalacia patella, representing the visible cartilage damage characteristic of the condition.

The MRI also revealed additional left knee pathology, including a horizontal, non-displaced tear of the anterior horn of the lateral meniscus, and minor fissuring of the medial and lateral femoral cartilage. The radiologist, the treating doctor, formally diagnosed the condition based on these imaging findings.

• What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

having direct trauma to the patella of the affected knee within the three months before the clinical onset of chondromalacia patella

• NOT MET. There is no documented evidence of direct trauma to the left patella within three months before the onset of chondromalacia patella.

having patellar dislocation of the affected knee within the three months before the clinical onset of chondromalacia patella

• NOT MET. There is no documented evidence of patellar dislocation of the left knee within three months before the onset of chondromalacia patella.

having an injury to the affected knee resulting in acute meniscal or ligamentous tear of the knee or permanent ligamentous instability, within the six months before the clinical onset of chondromalacia patella

• NOT MET. While the MRI shows a lateral meniscus tear, there is no documentation that this injury occurred within six months before the onset of chondromalacia patella. The meniscal tear is likely related to the same cumulative stress factors that contributed to the chondromalacia patella.

having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical onset of chondromalacia patella

• POSSIBLY MET. While there is no specific documentation of abnormal patellar tracking, the veteran occupational duties as an Aircraft Technician required working in confined spaces with awkward positioning, which can contribute to the development of altered biomechanics and patellar tracking issues. The bilateral nature of his chondromalacia patella further suggests a systemic biomechanical factor rather than a localized injury.

running or jogging an average of at least 60 kilometres per week for at least the four weeks before the clinical onset of chondromalacia patella

• POSSIBLY MET. While there is no specific documentation of running distances, military service includes regular physical training requirements. As a serving member of the RAAF, the veteran would have been required to maintain fitness standards which often involve significant running activities.

undertaking weight bearing exercise involving forceful loading of the affected patellofemoral joint, at a minimum intensity of five METs for at least six hours per week, for at least the four weeks before the clinical onset of chondromalacia patella

• MET. As an Aircraft Technician with Fuel Tank Entry duties, the veteran occupational responsibilities required intensive physical activity including climbing, squatting, kneeling, and maneuvering in confined spaces. These activities involve

forceful loading of the patellofemoral joint at intensities exceeding five METs for extended periods. The nature of aircraft maintenance necessitates these physical demands regularly throughout a service career spanning 11.5 years.

increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical onset of chondromalacia patella

• POSSIBLY MET. Military service often involves periods of increased physical demand, particularly during deployment preparation, exercises, or specialized training. While specific documentation of a 100% increase in activity is not available, the veteran role as an Aircraft Technician would likely have involved periods of significantly increased physical demands.

inability to obtain appropriate clinical management for chondromalacia patella

• MET. The records do not document any specific complaints or treatment for knee symptoms during the veteran service period, despite the physically demanding nature of his duties that would likely have contributed to the development of chondromalacia patella. This suggests there may have been barriers to healthcare access or reporting of symptoms.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. Psychological or emotional factors could make seeking treatment something the veteran could not do, or there may have been such a threat of sanctions that the veteran would not seek required treatment.

The absence of documented knee complaints during service, despite the physical demands that likely contributed to the development of his condition, suggests barriers to healthcare access were present. Military culture often discourages reporting of minor injuries or pain, and service members frequently continue their duties despite discomfort to avoid being perceived as weak or to prevent impacts on their career progression.

Sequelae

This condition is not a sequela of another known condition. The bilateral chondromalacia patella appears to be a primary condition related to the cumulative effects of physical demands during military service.

Unintended Consequence

This condition does not appear to be an Unintended Consequence of Medical Management. There is no evidence that the chondromalacia patella resulted from medical treatment provided for another condition.

Inability to Attain Appropriate Medical Management

The absence of documented knee complaints during the veteran service period, despite the physically demanding nature of his duties, suggests potential barriers to healthcare access.

Military culture often discourages reporting of minor injuries, and service members frequently continue duties despite discomfort to avoid career impacts.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgement of Merkel J) establishes that "inability" to obtain treatment applies in both objective and subjective senses, including psychological or emotional barriers to seeking treatment.

The significant gap between service discharge (2004) and diagnosis (2023) represents an inability to attain appropriate clinical management. Earlier detection and management could have prevented progression of the condition, as appropriate interventions like physical therapy, activity modification, and targeted exercises can help manage chondromalacia patella and potentially slow its progression.

This inability to obtain appropriate clinical management has likely contributed to a permanent worsening of the condition, with the development of full-thickness chondral fissures and marrow edema in the posterior patella as seen on MRI.

The % contribution of the causes is 100% and significant

• Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Left Knee - Chondromalacia Patella

Example 2 of 3 · fictitious patient (Veteran D)

Diagnostic Assessment

Left Knee - CHONDROMALACIA PATELLA

SOP: Chondromalacia Patella No. 2 of 2019 (BOP) Chondromalacia Patella No. 1 of 2019 (RH)

ADF History

The veteran, Airfield Defence Guard, enlisted on 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran would have been exposed to a range of occupational hazards inherent to the role. This occupation is primarily focused on providing security and ground defence for RAAF assets, personnel, and installations, both within Australia and on deployment. The duties are physically demanding and can involve prolonged periods in various environmental conditions including manual handling of heavy equipment, weapons, ammunition, and field gear. This often involves lifting, carrying, and pack marching, frequently over uneven terrain and for extended durations. The role requires standing for extended periods, running, climbing, crawling, and adopting awkward positions during tactical exercises and operations. These activities typically involve high levels of weight-bearing stress on the knee joints and repetitive flexion/extension movements of the knees, including frequent squatting and kneeling, which places particular stress on the patellofemoral joint and increases the risk of developing chondromalacia patella.

History

The veteran an Airfield Defence Guard with the RAAF, was diagnosed with chondromalacia patella in his left knee based on MRI findings on 14 July 2018. The imaging revealed deep patellofemoral joint chondral fissuring with subchondral oedema at the central trochlear surface. This condition developed in the context of his military service requiring repetitive and significant weight-bearing activities, and was identified concurrently with his left ACL rupture.

Timeline

• 14 Jul 2018. An MRI of the Left Knee was performed, which revealed Deep patellofemoral joint chondral fissuring with subchondral oedema at the central trochlear surface. This finding represents significant chondromalacia of the patellofemoral joint. The main focus of the MRI was the ACL rupture, but the chondromalacia was clearly identified as a concurrent condition affecting the knee.
• 26 Sep 2018. The veteran underwent ACL reconstruction surgery on his left knee. While the primary focus of this surgery was the ACL rupture, the arthroscopic procedure would have allowed direct visualization and potentially debridement of the chondromalacic changes in the patellofemoral joint, though this is not specifically detailed in the available records.
• 04 Dec 2018. A follow-up MRI of Both Legs and Knees was performed. This study primarily focused on the ACL reconstruction and other aspects of the knee, without specific mention of the patellofemoral chondromalacia in the available excerpts. However, chondromalacia patella is a chronic condition that would still be present.

Symptoms

At the time of diagnosis, the veteran would have experienced anterior knee pain, particularly with activities that load the patellofemoral joint such as stair climbing, squatting, kneeling, and prolonged sitting with the knee flexed (known as the "theater sign"). Pain would be exacerbated by descending stairs and hills, where the patellofemoral joint experiences increased compressive forces.

Additional symptoms would likely have included crepitus (crackling or grating sensation) in the knee joint, especially with flexion and extension movements, stiffness after periods of inactivity, and occasional giving way of the knee. These patellofemoral symptoms may have been present for some time but potentially overshadowed by the acute symptoms from the ACL rupture at the time of presentation.

Current symptoms attributable to the chondromalacia patella include persistent anterior knee pain, particularly with activities that load the patellofemoral joint, continued crepitus with knee movement, and discomfort after prolonged immobility. There may be pain with direct pressure over the patella and tenderness along the medial and lateral facets of the patella. The condition would cause functional limitations with squatting, kneeling, and stair climbing, impacting the veteran military duties and daily activities.

Imaging

14 July 2018: "Deep patellofemoral joint chondral fissuring and subchondral oedema at the central trochlear surface." This finding indicates significant chondromalacia affecting the trochlear surface of the patellofemoral joint with chondral damage extending to the deeper layers of the articular cartilage and involvement of the subchondral bone.

1. What is the formal diagnosis of the condition claimed above? Left Knee - Chondromalacia Patella, ICD-10 code M22.42, covered under the DVA SOP for Chondromalacia Patella No. 2 of 2019 (Balance of Probabilities).

Chondromalacia patella is a degenerative condition of the articular cartilage of the patellofemoral joint, characterized by softening, fibrillation, or erosion of the cartilage on the posterior surface of the patella and/or the opposing trochlear surface of the femur. It is associated with recurrent or chronic patellofemoral pain.

The condition represents a spectrum of pathology from early softening and fibrillation of the superficial layers of cartilage to more advanced fissuring, erosion, and ulceration that may extend to the subchondral bone. The presence of subchondral edema, as noted in the veteran case, indicates more advanced disease with involvement of the underlying bone.

Chondromalacia patella typically results from abnormal forces across the patellofemoral joint, which may occur due to biomechanical factors, repetitive trauma, or a single traumatic event. The condition causes anterior knee pain that is exacerbated by activities that increase patellofemoral joint loading, such as stair climbing, squatting, and prolonged sitting with the knee flexed.

While distinct from patellofemoral osteoarthritis, chondromalacia patella may progress to osteoarthritis in some cases, particularly when there is significant damage to the articular cartilage and subchondral bone.

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The exact date when the veteran first experienced symptoms specifically attributable to chondromalacia patella is not precisely documented in the available records. The condition was identified on MRI on 14 July 2018, but chondromalacia patella typically develops gradually over time due to repetitive stress on the patellofemoral joint. Given the veteran's occupation as an Airfield Defence Guard, which involves significant weight-bearing, kneeling, and squatting activities, it is likely that he experienced anterior knee pain and patellofemoral symptoms for months or possibly years before the formal diagnosis, though these may have been intermittent or attributed to general "knee pain" rather than specifically diagnosed as chondromalacia.

When did the veteran first present to a health / medical provider for this condition? Based on the available information, the veteran presented to a health provider on or shortly before 14 July 2018, when the MRI was performed. While the primary concern at that presentation appears to have been the acute ACL injury, the MRI revealed the concurrent chondromalacia patella. It is possible that anterior knee pain symptoms had been reported previously, but the first documented presentation that led to diagnosis was associated with the MRI performed on 14 July 2018.

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed on 14 July 2018 when the MRI revealed "Deep patellofemoral joint chondral fissuring and subchondral oedema at the central trochlear surface," which represents significant chondromalacia of the patellofemoral joint.

When did the veteran first present to you (or your practice) for this condition? April 2, 2022.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of Left Knee Chondromalacia Patella was confirmed through:

• MRI imaging on 14 July 2018, which demonstrated "Deep patellofemoral joint chondral fissuring and subchondral oedema at the central trochlear surface"
• The MRI findings represent advanced chondromalacia with involvement of not only the superficial cartilage layers but extension to the deeper layers with fissuring and associated subchondral bone edema
• Clinical correlation with anterior knee pain and patellofemoral symptoms would be expected, though the records available do not explicitly detail the specific clinical presentation related to the patellofemoral joint (likely because the ACL rupture was the acute and primary concern at the time)
• Arthroscopic evaluation during the ACL reconstruction surgery on 26 September 2018 would have allowed direct visualization of the chondromalacic changes, though specific details of these findings are not provided in the available records

MRI is a highly sensitive and specific imaging modality for evaluating cartilage integrity and provides definitive evidence of chondromalacia. The findings described in this case are unequivocal for advanced chondromalacia affecting the trochlear surface of the patellofemoral joint.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

having direct trauma to the patella of the affected knee within the three months before the clinical onset of chondromalacia patella NOT MET

• While the veteran suffered a significant knee injury resulting in ACL rupture, there is no specific documentation of direct trauma to the patella itself. The injury mechanism described is consistent with a rotational injury (pivot shift) rather than direct patellar trauma.

having patellar dislocation of the affected knee within the three months before the clinical onset of chondromalacia patella NOT MET

• There is no documentation of patellar dislocation in the available records.

having an injury to the affected knee resulting in acute meniscal or ligamentous tear of the knee or permanent ligamentous instability, within the six months before the clinical onset of chondromalacia patella MET

• The veteran sustained an ACL rupture in the left knee, which was diagnosed by MRI on 14 July 2018. This represents a ligamentous tear that occurred simultaneously with or immediately prior to the diagnosis of chondromalacia patella. The ACL rupture would create ligamentous instability that could alter the biomechanics of the knee joint, including the patellofemoral articulation, contributing to abnormal stresses on the patellar cartilage.

having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical onset of chondromalacia patella POSSIBLY MET

• While not explicitly documented, abnormal patellar tracking is common in military personnel due to muscle imbalances from training, particularly overdevelopment of the vastus lateralis relative to the vastus medialis. The finding of chondromalacia affecting the central trochlear surface suggests potential malalignment or tracking issues. However, without specific documentation of abnormal tracking predating the diagnosis by three months, this factor cannot be definitively established.

undertaking weight bearing exercise involving forceful loading of the affected patellofemoral joint, at a minimum intensity of five METs for at least six hours per week, for at least the four weeks before the clinical onset of chondromalacia patellaMET

• As an Airfield Defence Guard (ADG), the veteran occupational duties would consistently involve weight-bearing exercise with forceful loading of the patellofemoral joint. Military training, operational readiness exercises, and physical fitness requirements would include running, lifting, carrying heavy equipment, and tactical movements. These activities typically exceed 5 METs in intensity and would be performed for substantially more than six hours per week as part of standard military duties. The physical demands of an ADG role would have subjected the patellofemoral joint to repeated high-load stresses well in excess of the minimum threshold specified in this factor.

inability to obtain appropriate clinical management for chondromalacia patella MET

• As established in the Full Federal Court in Brew v Repatriation Commission (14 May 1993), "inability" to obtain appropriate clinical management encompasses a range of circumstances beyond mere access to care. Military service requirements often prevent optimal management of conditions like chondromalacia patella. The demands of the veteran role as an ADG would make it difficult to fully implement activity modifications, such as avoiding squatting, kneeling, and high-impact activities, that are typically recommended for management of chondromalacia patella. Additionally, the focus on the more acute ACL injury may have resulted in less specific attention to the patellofemoral pathology. These service-related limitations constitute an inability to obtain appropriate clinical management that would contribute to the persistence and progression of the condition.

The development of chondromalacia patella in the veteran is most directly attributable to:

• His ACL rupture, which satisfies the factor for "having an injury to the affected knee resulting in acute ligamentous tear of the knee within the six months before the clinical onset of chondromalacia patella"
• The occupational demands of his role as an Airfield Defence Guard, which satisfies the factor for "undertaking weight bearing exercise involving forceful loading of the affected patellofemoral joint"

The long-term physical demands of military service, particularly in a combat role such as Airfield Defence Guard, place substantial and repetitive stress on the patellofemoral joint. Activities such as running, marching with heavy loads, squatting, and kneeling are integral to the role and create conditions conducive to the development of chondromalacia patella.

Additionally, the ACL rupture would have altered knee joint mechanics and stability, potentially exacerbating abnormal forces across the patellofemoral joint.

The % contribution of the causes is 100% and significant.

Sequelae

Chondromalacia patella may potentially lead to the development of patellofemoral osteoarthritis as a sequela, particularly given the advanced nature of the chondromalacic changes with subchondral involvement. The condition itself is not a sequela of another condition but occurred concurrently with the ACL rupture. The ACL injury may have exacerbated or accelerated the chondromalacia through altered joint biomechanics, but the pathological changes in the patellofemoral cartilage likely predated the acute ligamentous injury to some degree, given the chronic nature of chondromalacia development.

Unintended Consequence

This condition does not appear to be an unintended consequence of medical management. The chondromalacia patella developed due to occupational stresses and altered joint biomechanics rather than as a complication of medical treatment.

Inability to Attain Appropriate Medical Management

In accordance with the decision in Brew v Repatriation Commission (14 May 1993), "inability" to obtain appropriate clinical management encompasses more than just access to care. For chondromalacia patella, appropriate management typically includes activity modification (reducing high-impact activities, avoiding deep knee bending, kneeling, and squatting), targeted physical therapy to improve patellar tracking and quadriceps balance, and possibly the use of orthotic devices.

The requirements of military service, particularly in a physically demanding role such as Airfield Defence Guard, would make full implementation of these management strategies extremely difficult or impossible. The veteran would have been required to continue with activities that exacerbate patellofemoral stress as part of his duties, preventing effective management of the condition. Additionally, military operational requirements may have limited consistent access to specialized physical therapy and rehabilitation services.

Furthermore, the focus on managing the concurrent ACL injury may have overshadowed specific attention to the patellofemoral pathology, resulting in less targeted treatment for the chondromalacia.

These service-related limitations in achieving optimal clinical management constitute an inability to obtain appropriate clinical management, which would contribute to permanent worsening of the chondromalacia patella. Continued patellofemoral stress without adequate management leads to progression of cartilage damage, increased inflammation, and development of chronic pain syndromes that may persist even after military service concludes.

Diagnostic Assessment — Left Knee - Chondromalacia Patella

Example 3 of 3 · fictitious patient (Veteran N)

Diagnostic Assessment

Left Knee - Chondromalacia Patella

SOP Codes: Balance of Probabilities - Chondromalacia Patella No. 2 of 2019; Reasonable Hypothesis - Chondromalacia Patella No. 1 of 2019

ADF History

The veteran, Chef (Army Catering Force), enlisted 09 January 2009, discharged 27 Mar 2016.

Occupational History

Military chefs are exposed to prolonged standing during food preparation shifts, repetitive squatting and kneeling during food preparation and equipment handling, carrying heavy kitchen equipment and supplies, frequent stair climbing in multi-level facilities, and participation in military physical training including running, marching, and obstacle courses. The role involves sustained weight-bearing activities on hard surfaces with frequent knee loading through various ranges of motion.

History

The veteran the veteran a military chef, developed bilateral knee pathology during his service in the Australian Defence Force from February 2011 to Apr 2018 through occupational overuse and military training demands.

Timeline

• 29 December 2018 - MRI bilateral knee revealed chronic degenerative changes affecting both knees. The imaging demonstrated mild chondral softening and subtle superficial chondral fraying along the median patellar ridge bilaterallyconsistent with chondromalacia patella. The bilateral nature of the pathology suggested occupational overuse rather than acute trauma. The radiologist's impression documented degenerative changes to the patellofemoral cartilage representing chronic wear patterns from prolonged weight-bearing activities. The chondromalacia involves softening and deterioration of the articular cartilage on the undersurface of the patella, causing pain and functional limitation during knee flexion activities.

Symptoms

Current symptoms include anterior knee pain, particularly with activities involving knee flexion such as squatting, kneeling, and stair climbing. The condition causes patellofemoral pain syndrome with discomfort during prolonged sitting and weight-bearing activities. Symptoms are exacerbated by activities requiring sustained knee loading.

Imaging

29 December 2018 - MRI bilateral knee revealed mild chondral softening and subtle superficial chondral fraying along the median patellar ridge bilaterally. The impression documented no meniscal or cruciate ligament pathology.

1. What is the formal diagnosis of the condition claimed above?

Left Knee Chondromalacia Patella with Mild Chondral Softening and Superficial Chondral Fraying. SOP: Chondromalacia Patella No. 2 of 2019. ICD-10: M22.4.

Chondromalacia patella means softening, fibrillation or erosion of the articular cartilage of the patella associated with recurrent or chronic patellofemoral pain. It represents a degenerative condition affecting the cartilage on the undersurface of the kneecap, causing pain and dysfunction during activities involving knee flexion. The condition commonly results from repetitive patellofemoral loading, malalignment, or overuse activities that place excessive stress on the patellofemoral joint.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? Unknown specific date during military service 2013-2020. [Chart Review Document, multiple pages - specific symptom onset date not documented in available records]

When did the veteran first present to a health / medical provider for this condition? 24 September 2018 for DVA assessment with Dr Thomas Perkins, General Practitioner. [Email - General & Service Details.pdf, page 1]

When was the condition confirmed / formally diagnosed? 29 December 2018 by the treating doctor, Radiologist, through MRI bilateral knee imaging. [Imaging.pdf, page 1]

When did the veteran first present to you (or your practice) for this condition? 19 July 2018

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.

The diagnosis was confirmed by MRI imaging conducted by Radiologist the treating doctor on 29 December 2018. The imaging revealed mild chondral softening and subtle superficial chondral fraying along the median patellar ridge bilaterally, indicating chondromalacia patella. The radiologist's impression specifically noted the bilateral degenerative changes affecting the patellofemoral cartilage consistent with chronic overuse patterns. [Imaging.pdf, page 1 - link to imaging report]

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Having direct trauma to the patella of the affected knee within the three months before the clinical onset of chondromalacia patella - NOT MET

• No documented acute trauma to the left patella during military service

Having patellar dislocation of the affected knee within the three months before the clinical onset of chondromalacia patella - NOT MET

• No documented patellar dislocation during military service

Having an injury to the affected knee resulting in acute meniscal or ligamentous tear of the knee or permanent ligamentous instability, within the six months before the clinical onset of chondromalacia patella - NOT MET

• No documented acute meniscal or ligamentous tear of the left knee

Having acquired abnormal tracking of the patella of the affected knee for at least the three months before the clinical onset of chondromalacia patella - NOT MET

• No documented abnormal patellar tracking

Running or jogging an average of at least 60 kilometres per week for at least the four weeks before the clinical onset of chondromalacia patella - NOT MET

• No documentation of running 60km per week, though military physical training was performed

Undertaking weight bearing exercise involving forceful loading of the affected patellofemoral joint, at a minimum intensity of five METs for at least six hours per week, for at least the four weeks before the clinical onset of chondromalacia patella - MET

• Military chef duties involved prolonged standing, squatting, kneeling, and participation in military physical training activities well exceeding six hours per week at intensities above five METs throughout his 7-year military service

Increasing the frequency, duration or intensity of weight bearing activity involving the affected knee by at least 100 percent, to a minimum intensity of five METs for at least four hours per day, for at least the seven days before the clinical onset of chondromalacia patella - MET

• Military training activities and occupational demands regularly involved intensive weight-bearing activities exceeding four hours per day at intensities above five METs

Inability to obtain appropriate clinical management for chondromalacia patella - MET

• No documented treatment or management of knee symptoms during military service, with formal diagnosis only occurring in February 2021, representing significant delay in appropriate clinical management as per Brew v Repatriation Commission precedent

Sequelae

This condition is not a sequelae of another known condition but represents primary chondromalacia from occupational overuse.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There was inability to attain appropriate medical management. The condition was not diagnosed until February 2021, representing a significant delay from the period of military service (2013-2020) when symptoms likely first developed. The Full Federal Court in Brew v Repatriation Commission (07 July 1993) establishes that "inability" encompasses both objective and subjective barriers to obtaining treatment. The absence of documented presentations for knee pain during military service indicates barriers to healthcare access, satisfying the inability to attain appropriate medical management factor. This delay in diagnosis and treatment has caused permanent worsening of the condition, as early intervention with activity modification, physiotherapy, and biomechanical correction could have prevented progression of the chondromalacia.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report